Fludarabine-containing chemotherapy for patients with previously untreated low-grade non-Hodgkin's lymphoma

Autoimmune thrombocytopenia: a complication of fludarabine therapy in the treatment of Waldenstrom's macroglobulinemia

Fludarabine is an effective purine analogue which has become extensive used in lymph proliferative malignancies. However, an increased incidence of autoimmune disorders including autoimmune hemolytic anemia (AHIA) and idiopathic thrombocytopenia (ITP) is reported with the use of fludarabine. The exact mechanism for fludarabine to exacerbate thrombocytopenia is not distinct. In our report, we describe a patient with WM developed a refractory, life-threatening and fludarabine-associated thrombocytopenia which could not be explained by the cytotoxic effects of fludarabine. Possible mechanisms of fludarabine on autoimmune disorders are discussed.

Successful transplantation of kidney allografts in sensitized rats after syngeneic hematopoietic stem cell transplantation and fludarabine

Current methods to remove donor-specific HLA antibody (DSA) from sensitized patients remain imperfect. We tested novel approaches to desensitization using an animal model of allogeneic sensitization with skin grafts from dark agouti (DA) to Lewis rats. At the peak IgG alloantibody response we transplanted DA kidneys into nephrectomized Lewis recipients (n = 6) and all died within 10 days from antibody-mediated rejection (AMR). Allogeneic hematopoietic stem cell transplants (HSCT) from DA donors failed to engraft after lethal or sub-lethal irradiation. Sensitized rats given lethal irradiation plus syngeneic green fluorescent protein (GFP) + HSCT had repopulation of blood, spleen, thymus and lymph nodes by GFP+ cells. At 2 months after HSCT, serum DSA levels were reduced 60-70% and DSA (IgG) production in cultured splenocytes was also significantly decreased. However, there was only a modest improvement in graft survival from an average of 6.5 to 13.9 (n = 9) days. Adding seven daily doses of fludarabine to the preconditioning regimen resulted in long-term survival (>90 days) in 7 out of 10 rat kidney allografts. We conclude that syngeneic HSCT performed after preconditioning with irradiation and fludarabine can reduce DSA, prevent DSA rebound and AMR, enabling successful transplantation in animals with strong antibody reactivity to the donor MHC.